Systematization of nursing care: challenges and features to nurses
in the care management
Sistematização da assistência de enfermagem: facilidades e desaios do enfermeiro na gerência da
assistência
Sistematización de los cuidados de enfermería: facilidades y desafíos de enfermeros en el soporte de
gestión
Mirelle Inácio Soares1
Zélia Marilda Rodrigues Resck1
Fábio de Souza Terra1
Silvia Helena Henriques Camelo2
1. Federal University of Alfenas. Alfenas - MG,
Brazil.
2. University of São Paulo. Ribeirão Preto - SP,
Brazil.
Corresponding Author:
Mirelle Inácio Soares.
E-mail: mirelleenfermagem@gmail.com
Submited on 11/05/2013.
Accepted on 10/21/2014.
DOI: 10.5935/1414-8145.20150007
AbstrAct
Objective: To analyze the advantages and challenges of nurses in instrumental assistance management by Systematization
of Nursing Assistance (SNA). Methods: This is a qualitative study, based on the framework of dialectical hermeneutics. The
sample consisted of 32 nurses from three hospitals in a city in southern Minas Gerais. We used the Focus Group with the guiding question: "What are the facilities and the challenges for the implementation of the SNA in the management of assistance?". After the interviews, the speeches were transcribed verbatim. Content analysis of the data allowed to extract the category Facilities and challenges for SAE in the daily work of nurses. Results: The results showed facilitators and challenging points, in
which participants consider the SNA a facilitator in planning and organization of care, however, there are internal issues in the institutions that serve as barriers to nurses in its implementation. Conclusion: However, the successful implementation of the
SNA happens through a mutual development.
Keywords: Nurses; Management; Hospitals; Nursing Process; Patient Care.
resumo
Objetivo: Analisar as facilidades e os desaios do enfermeiro na gerência da assistência instrumentalizado pela Sistematização da
Assistência de Enfermagem (SAE). Métodos: Trata-se de um estudo qualitativo, fundamentado no referencial da
Hermenêutica-Dialética. A amostra constituiu-se de 32 enfermeiros de três Hospitais de um município do Sul de Minas Gerais. Utilizou-se o Grupo Focal com a questão norteadora: "Quais são as facilidades e os desaios para a implementação da SAE na gerência da assistência?". Após as entrevistas, as falas foram transcritas na íntegra. A análise de conteúdo dos dados possibilitou extrair a categoria Facilidades e desaios para a SAE no cotidiano de trabalho do enfermeiro. Resultados: Os resultados mostraram
pontos facilitadores e desaiadores, onde os participantes consideram a SAE facilitadora no planejamento e na organização da assistência, porém, existem aspectos internos nas instituições que servem como entraves ao enfermeiro na sua implementação.
Conclusão: No entanto, o sucesso da operacionalização da SAE se dá por meio de um desenvolvimento mútuo. Palavras-chave: Enfermeiros; Gerência; Hospitais; Processos de Enfermagem; Assistência ao Paciente.
AbstrAct
Objetivo: Analizar las ventajas y los retos de la enfermera en la gestión de la asistencia instrumentalizada por la Sistematización
de la Asistencia de Enfermería (SAE). Métodos: Estudio cualitativo, de referencial hermenéutico-dialéctico. La muestra contó
con 32 enfermeras de tres hospitales de una ciudad en el sur de Minas Gerais. Se utilizó el grupo focal con la pregunta guía: "¿Cuáles son las facilidades y los retos para la aplicación de la SAE en la gestión de la ayuda?". Después de las entrevistas, los discursos fueron transcritos. El análisis de contenido de los datos permitió extraer la categoría Instalaciones y desafíos para SAE en el trabajo diario de las enfermeras. Resultados: Los participantes consideran la SAE facilitadora en la planiicación
y organización de la atención, sin embargo, hay problemas en las instituciones, que sirven como barreras. Conclusión: La
implementación exitosa de la SAE se da a través de un desarrollo mutuo.
INTRODUCTION
Since past decades in diferent health services, especially in hospitals, nursing management has assumed crucial importance in linking the various professionals of the healthcare team and the organization of nursing work for those who seek these services. It is understood that the hospital organization is one of the most complex health care services due to the coexistence of numerous assistance and administrative processes, and fragmentation of assistance decision processes with the presence of a multidisciplinary team with a high degree of autonomy. Thus, it uses technology intensively and extensively, and may constitute itself into a space for teaching and learning and also a ield of scientiic production1.
In this context, nurses experience a challenge in building and compilation of knowledge on which is based its management and assistance practice. The development of nursing work process is part of this challenge, to realize the proposal of promoting, maintaining or restoring the health status of the patient. Thus, the Systematization of Nursing Assistance (SNA) is to add and shape the planning, execution, control and evaluation of the actions of direct and indirect patient care2.
It is noteworthy that there are diferent ways of systematizing nursing care, among which we can mention the care plans, protocols, standardization of procedures and the nursing process. These are diferent ways to develop care, in other words, various methods can be used to solve a real situation at a given time in order to achieve positive outcomes for patient health. These modes of action are not mutually exclusive and have diferent natures3.
As a result, it is understood that nursing management and assistance are key functions in daily nurse, aiming for excellence in the quality of health care ofered to the patient, the family and the community with intervention in the health-disease process.
From this premise, SNA is located as an instrument of the assistance process of the nurse, which can help to ensure the quality of care, since it includes a range of tools that include communication, interaction and articulation of management and assistance dimensions4.
Accordingly, in an attempt to facilitate the operation of SNA, nursing staf often, initially, decides for piecemeal work. But this systematized work is still incipient with assistance practice, being more present in the ideal scenario, guided by the management and assistance models based more on management theories than on the actual making of everyday life in the hospital setting. The nurse in the hospital environment develops numerous tasks with high demands and responsibilities which depending on how they are systematized and his knowledge of management tools able to assist him, may impair the quality of care. Thus, this study presents the following questions: What are the facilities and the challenges of the nurse in hospital management? Can the SNA help nurses in the management of care? What are the facilitator mechanisms used by the nurse to the implementation of the SNA? What are the challenges and limitations that pervade nurses' everyday-work in face of the implementation of the SNA?
Carrying out this study is justiied in order to contribute to the relection of nurses about the need to implement the SNA as a strategy for care management, achieving autonomy and space in an attempt to break the dichotomy between what is recommended and what is achieved in daily nursing, contributing to the planning and organization of the management and assistance practice. With that, this research aims to analyze the facilities and challenges of the nurse in the management of assistance instrumentalized by SNA.
METHOD
This is an exploratory study, with qualitative approach, grounded in the theoretical and methodological framework of dialectical hermeneutics, considered an empirical research method, which reveals a belief in the process of moving that exists permanently in society as well as in the historic building and in the ability of transformation and overcoming contradictions through praxis5.
The ield work of research was developed at the place where the nurses are working, and consisting of three hospitals in a city in southern of Minas Gerais, such as public teaching hospital, public general hospital and private one. The total of 85 nurses of those institutions were invited to participate in the research, and the selection was made through invitation letter, telephone and e-mail.
Given this opportunity, it was presented the research objectives, the importance of their adherence to the realization of this research, the assurance of anonymity, seeking to reduce concern of any future exposure.
It is important to emphasize that the reaction of these participants was partial, appearing in the days and hours scheduled by agreement of the nurses invited, only those who accepted to participate in this research.
To collect empirical material, we chose the focus group technique using digital recorders to record the speeches of the participants. In developing work together with focus groups, 32 of 85 nurses invited comprised the sample, since according to the Dimension of Nurses in each hospital, it was performed six meetings, of these a focus group with four nurses occurred in private hospital in December 2012, two focus groups occurred at the public hospital in January 2013, and of these two groups, both were made up of seven nurses, and three focus groups occurred in public teaching hospital in February 2013, the irst group consisted of ive nurses, the second of four nurses and the third of ive nurses. It is noteworthy that each focus group was held in the very hospital required, where the groups were performed consecutively and were arranged according to periods of work, i.e., shifts of morning, afternoon and evening as well as the availability of each nurse to participate in focus groups.
This study was approved by the Federal University of Alfenas, Research Ethics Committee (Unifal-MG), Opinion Nº 139518/2012, CAAE 08899312.8.0000.5142. The nurses signed the Informed Consent Form (ICF), as recommended by the Resolution of the National Health Council (CNS) 466/126.
For data analysis we used the content analysis technique proposed by Minayo7, comprising three basic phases:
pre-analysis, exploration of material and treatment results. Pre-analysis is considered the organizational phase of the study, with the irst step in organizing the data collected in the focus groups conducted with study participants, preceding the transcription of DVRs, respecting the speeches in full.
The material exploration phase is the analysis itself, it is an ample moment of the study, since it requires a movement of coming and going of speeches in order to explore in depth the available material.
The phase called treatment of the results allows researchers to propose inferences and perform subsequent interpretations foreshadowed in the theoretical framework, glimpsing new fronts, serving as a basis for further analysis, alluded by reading the material for new theoretical dimensions held by the Hermeneutic-Dialectic Method.
RESULTS AND DISCUSSION
To better emphasize the understanding of the empirical category of the study, the characterization of the participants was held, stressing that all nurses are responsible for units of small, medium and large complexity sectors. Among these, the female sex was predominant, aged between 20-40 years old. Thus, data showed professionals with some type of Lato Sensu Postgraduation and only one nurse owned Stricto Sensu
Postgraduation. The length of service ranged from one year to 25 years in the profession; of these 10 nurses were graduated from public institutions and 22 by private institutions.
Related to the 32 nurses who participated in the study, 10 were nursing technicians before completing the Nursing Graduation; two nurses had more than 20 years since graduation; seven more than 10 years since graduation, and the other 23 had from one to 10 years since graduation. Thus, two categories have emerged from the qualitative data: "Facilities for SNA in the daily work of nurses" and "Challenges for SNA in the daily work of nurses".
Facilities for SNA in the daily work of nurses
Given the technological evolution, the constant exchange of information and demands of health institutions in an efort to maximize resources, reduce costs and improve quality of care, it has been increasingly demanded the improvement of nursing services, planning and operationalizing care, reinforcing the undeniable need to adopt and consolidate the SNA8,9.
Improving on the excellence of the quality of nursing care has conformed a need to change practice and the role of the nurse in order to bring a new feature to his performance10. Thus, despite
failing to implement the SNA in the daily work, the nurse is aware
that it directs the planning and organization of care activities and functions of members of the nursing staf, which is observed in the following speech:
[...] with the systematization you become more indepen-dent because it is deployed, it has a protocol of systema-tization, I guess that it leaves you freer to do something else by the patient and not having the systematization, not having this protocol [...] you depend on the doctor, you get more tied... (N06).
Thus, the nurse also gets committed to involve the whole nursing staf, always showing the importance of systematic care for awareness and active participation of managers. However, despite diiculties related to the implementation of the SNA under managerial point of view, there is an appreciation by nurses regarding the need to systematize care, working as a motivational factor and a concern not only in dedicating themselves to implementation of activities in the health care guarantee, as well as in the beneits that the systematization can ofer to the customer and to the nurses9.
[...] I think it is necessary because it is a tool to qualify the nursing work. (N03).
[...] there is no way to work without systematization, be -cause you do it automatically, anything you do with the patient is inside the systematization [...] (N06).
[...] we think that the systematization will improve further,
we have a lot to improve, but when we implement just a little bit, we see that we can get satisfactory results. (N20).
However, it is notable emphasize in this study that nurses, for not having SAE implemented, end up performing their actions in accordance with the priorities of their work process.
[...] we work according to priority of gravity, it is a very
dynamic sector, we do not have systematization, we accept outpatients and we accept more severe patients, logically we prioritize to the most serious, and we [...] attend according to the severity level. (N03).
It is observed in health facilities, especially in the hospital, where there is a large contingent of nurses, that there is a constant efort to ofer quality care in nursing using the SNA tool, which should facilitate the process of nurses' work, as well generate positive results not only for the organization, but also to meet the needs of clients and their families. However, care and nursing services management involve complex actions, requiring knowledge in the acquisition of new tools which is a major factor in deining the practice of professional11.
Challenges for SNA in the daily work of nurses
legalization it has been required within the Brazilian health institutions. Nevertheless, today, we can still observe that this resolution alone does not provide all the necessary support for its implementation, since many factors trigger practical diiculties in the implementation process of this assistance tool9.
[...] I noticed many times that it was a legal requirement
that had to be fulilled [...] (N04).
I think we' have always done it, now that the word is at
the pinnacle, it is systematization, we have always done it, but we have never named it as systematization [...] we have always this done since long before, before hearing
about systematization [...] (N15).
We can do something, we already do much, but we do not put these things on paper, [...] and you cannot prove you did it... the proof that you did it, that you wrote it,
nothing. We do not know how to put it; we do not know
how to prove [...] we made everything. (N18).
These notes bring up one of the major problems highlighted in this research: the failure of the nurse records in relation to SNA. It was realized that the lack of recording, i.e. not putting on paper, makes SNA to become informal, hindering its implementation. Therefore, the unsatisfactory completion of the nursing record makes SNA incomplete and inoperative, revealing a contradiction between what is said and what is practiced4.
Thus, it was realized by the nurses' testimonies a diiculty to systematize the assistance correctly:
So I believe we have an informal systematization which often is not written or described, but we have a labor organization, especially when we are on duty... so... we have actions to perform [...] (N01).
[...] the systematization of care here [...] from what I see [...] is very informal, it is done automatically, but with
no record of anything [...] So I think we need to have a formalization, because everything that is informal gets like this, one throwing to another. I think when the institution
intends to do something, it has to formalize it [...] so it is a process that we can do... but from the moment it was not put on paper, ah! [...] There is no use, it does not
work. (N06).
[...] it is not a written, formalized systematization, but it is
already a routine, a sequence of work that comes out of
a structured way. (N11).
For nurses participating in the study, little or no systematic recording of SNA may result, on the one hand, in the absence of visibility and professional recognition; on the other hand, which is perhaps more serious, in the absence or diiculty in evaluating their practice13. Thus, the lack of a protocol, print and/or paper
is evidenced as a hindrance in daily nurse.
As they say, it does not follow a rhythm, it does not have a protocol [...] we do not have the pace yet, we do not
have a record like that... we just observe, then we see if
there are results or not, it is more direct, it does not have
the script itself. (N07).
[...] it does not have anything to formalize yet, but you may do the prescription to the technician follows [...] but there is nothing formalized [...] (N09).
[...] demands are on paper, on the paper, they demand
the paper [...] because once the Health Surveillance staf spoke: Look! [...] You do everything, we know, but it can
-not be proved. There is -nothing recorded, except on the prescription where you put ok, or the time you checked
or the nursing report, if you have it [...] but there are some
things that have to be registered [...] (N15).
Added to that, the greater the number of demands afected of the patient, the greater the need of planning assistance, since the systematization of actions aimed at planning and organizing, the validity and eiciency of care provided14. This can be seen
in the testimony of nurses:
[...] we have returns to be received, so we get on duty and
we deine what the priorities are. So of these priorities we
see if there is any patient who requires some special care
[...] if we have any pending [...] we take it as a priority to be resolved... in our routine work, we systematized by
priorities that must be made [...] (N01).
[...] I think this is what is missing now [...] a little more
than we having this opportunity to provide for the patient a better quality of care, which is the systematization [...]
(N15).
The SNA is planning actions, which are based on the development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the identiied problems and achieve the identiied goals and expected outcomes14.This
is referenced by the nurses participating in the study:
[...] I punch the vein, I do bandage and when the nurse has this view of systematization, this view of implementing
the plan, he comes to perform a task, I believe that things
have a faster return [...] (N01).
When you arrive, the irst thing you do is planning what
you will do with the patient [...] (N14).
[...] I see that the issue of planning is also a very serious
issue, we are lost, for example, on the indicator issue, when the Surveillance staf comes, they want you to do
will be done and I watch side by side with the technicians, going up to the bedrooms [...] acting alongside them. (N30).
Thus, implementing SNA is currently regarded as a challenge, especially with regard to management of care, since a complex, multifaceted and multidimensional reality requires from nurses commitment and creativity in developing and implementing in
-novative and participatory strategies and to maintain favorable conditions for the adoption process of SNA, involving political and economic issues for hospital accreditation12. This fact is referenced
by nurses, since even not having the structured SNA, they create a means of implementing this instrument, but in a piecemeal way:
[...] there is a great assistance demand and it is one nurse per sector, then they even try, it is not that systematization as it is on paper, but it is adapted to our reality [...] (N23).
[...] we still do not have systematization [...] to speak the truth, we have a checklist, which raises issues and our evolution, but it is a very poor thing [...] (N27).
Professionals point to the lack of training as one of the limitations for the implementation and execution of the SNA, and the lack of knowledge from nurses the main reason for the lack of commitment in some health institutions and the absence in others, while this ignorance generates disinterest and lack of adherence to care method15.
[...] before you act, you already expect return, which is
what the systematization assures us, if we perform well,
our return will be quicker [...] (N01).
[...] we are pretty excited to deploy the systematization of
nursing... (N32).
It is noteworthy that during the course of SNA, many nurses are faced with several critical factors in its implementation, requiring its adjustment to the reality of the moment and the health institution, since many have administrative and welfare problems, especially in public organizations, considered as barriers in improving quality of care9.
With this, it is regarded the knowledge of nurses, as well as the training of the nursing staf for implementing the SNA within the institution itself. This because nurses are trained in diferent schools and taught diferently. In addition, it is needed to enable nurses in relation to the speciicities of this methodology in the institutional context12. This fact was conirmed by the testimony
of the nurse N07:
[...] because systemization is made in ive stages, I do not remember the ive, because it is been a while, [laughs ...] it is divided into ive phases, implementation, data
collection, I do not remember the order, then you have to study where you are going wrong to try to improve [...].
Another issue pointed out by one of the nurses related to non-operationalization of SNA was the lack of an environment for information about changing shifts:
[...] I think the first fault here, we do not have an environment where the shift change happens, I think the
shift change needs to be held in a private room, a place
for this, where you are calm, you have peace [...] (N27).
However, despite the physical structure in the literature is underreported for the operationalization of SNA, its analysis is essential when the idea is to deploy it. An example of this fact is that the existence of a private room for exchange of information about the attendance can mean a space for professionals to express themselves freely, helping to deine the nursing actions that will be put into practice by SNA12.
However, the time factor also represents one of the fundamental features of an organization and its management contributes to improvements in individual and collective performances in productivity. Thus it arises the need of shaping tools in nursing actions according to each institution by entering facilitator software on progress of activities, trying to overcome these limitations16.
In addressing the SNA through the electronic medical record, it is understood that nursing records permeate all stages and should be noted in the patient's record complete information about the history, physical examination, nursing diagnoses, the prescription of assistance and the evolution/ nursing assessment17.
However, it should be added that, apart from the advantages of electronic medical records for the SNA, the nurse still realizes that it brings many obstacles in the registry of nursing activities. However, it is realized that, in practice, the SNA is still far from being properly implemented in its entirety, since the systematic making of records, which is essential for its consolidation, is still not a routine work in nursing in many institutions17.
[...] documented, actually, we do not have, there is the
nursing report, to speak that it is ours, of the nurses, we
write what we do, every day [...] (N18).
[...] we have many problems with the electronic medical record. It is an issue of prescription quantities, that some-times we have to be aware [...] (N28).
[...] to record on paper is hard, then to execute is more, because it is the assistance itself. On the paper it is not
done properly. (N30).
It is perceived that nurses still face many obstacles related to nursing records that impair efective realization of SNA.
[...] sometimes there are people who think that nursing
report is not even a document, I have seen doctors who
have never read it. (N15).
[...] the issue of nursing report, there was a time it was
kind of bad... there were a lot of repeated information,
some put things that were not so important, left out those
that mattered, we managed to ix this, it is not perfect, but
vastly improved. (N26).
Thus, it is important to question how the nursing staff perceives their records for the realization of SNA, which will only be an efective practice if it is discussed and defended by the very professional category17. This fact greatly complicates
communication among nurses, which is seized by the nurse N09:
[...] even on paper records the employee does not write
properly, one way or another it is poor, it has ive little lines
there all night, it does nothing.
It is noteworthy that the activities of nurses are divided by shift work and communication between teams of diferent shifts occurs, in hospital reality, through the occurrence book, which often replaces the shift change, and also, most of the time, the patients' records and other legal forms of information and communication17.
For nurses in the study, recording the attendance in the book of complications is essential for professional support.
I think that the book is important for you to make a shift
change, because it will be there anyway, you are
regis-tering there [...] in my duty, people think I write too much in those shift changes books, but many of the things that happens in day to day life, I record on that book. If it is to be only complication in that book, if it will serve to someone one day, I do not know, but it is recorded there, it is. (N12). I like to record everything, sometimes my record is huge, I think it' is the support you have there, I like to write down
almost everything, I enjoy writing quite a lot. (N31).
It is observed by the speeches of the nurses that there is the awareness of the importance of nursing records as a legal support, which COFEN, from the Resolution Nº 308/2009 establishes the SNA as one of their private activities, which must occur in every institution of public or private health care. This duty is recognized in its legitimacy and importance, despite not being performed by some of the nurses interviewed17,18.
[...] you end up losing yourself with so much paper and
it is very bureaucratic, you have many books, too much
bureaucracy, we try to get some things out, but there is
no other way, you ill book by book and the patient? It is
too bureaucratic, you cannot handle it... So it is, there are
many books, there is a lot of bureaucracy. (N18).
Given these not systematized notes, it is imperative that nurses take ownership of the management tools to transform the care process, that when considering that managing the care is, among other things, arranging care, they are building a relationship between the SNA and the very management of care4.
CONCLUSION
The hospitals have speciic characteristics with regard to the facilities and challenges for the operationalization of the SNA, which should be analyzed by the nurses, in order to implement this assistance tool with real knowledge of the situation and possible goals to be achieved.
The low of testimonials seized lead to envision scenarios of everyday life of nurses in which a fragmentation still occurs in their work process, where this work for so many reasons does not accomplish SNA in a systematic and individualized way.
Thus, it is clear to emphasize that in the reality of the hospitals surveyed, through focus groups, several situations were pointed oud in which sometimes the professional fails to exercise its actions on account of which it is imposed in the face of global changes and transformations.
In this sense, making an articulation of the results, one can notice that there are more challenges than facilities that pervades the nurses' every day in face of operation of SNA, such as the correctly implementation of SNA, the lack of forms, protocols, scarcity nurses, which creates a lack of time, lack of knowledge, i.e., not professional training, lack of an environment for the shifts change as well as incomplete nursing records.
However, all participants recognize the importance of SNA for an individualized and quality care; however, these barriers cited leaves the nurse hands tied, not having the necessary support to implement it. Thus, by the discourses of nurses it is notorious to emphasize that they have been struggling to implement the SNA in the institution of action.
However, the successful operation of SNA takes place by means of a mutual development in which people are valued by the organization at the extent that they effectively contribute to its development as well as organizations are valued by people in the extend that they offer concrete conditions for their growth.
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